Application for Volunteer Services
Personal Data
Educational Data
(Do not list relatives) Please list individuals who can confirm special skills, training experience noted above.
Employer or Former Employer
I certify that the information provided on this application (and all attachments) is true and complete. I understand that Providence Medical Center or Saint John Hospital will not be able to consider an incomplete application. I understand that any false statements, misleading representations or omissions may disqualify me from further consideration for volunteer service and result in discharge, if discovered at a later date. I understand that Providence or Saint John will seek to verify and confirm information provided in this application. I authorize agencies, persons, schools, my current employer (if applicable) and previous employers/organizations named in the application to provide Volunteer Services with any relevant information including consumer reports, regarding a volunteer assignment. In doing so, I release all such persons from any liability regarding the provision or use of such information. I will agree to medical examinations and/or tests, which may include chest X-ray, tuberculin skin tests and immunizations that may be necessary as part of my volunteer service. I authorize my doctor(s) to furnish the hospital information concerning my health. I also authorize the person(s) making tests or x-rays to report the results to the hospital. In addition, if I apply for a volunteer assignment that requires driving I will be required to undergo testing for illegal use of drugs and alcohol consumption. In consideration of my volunteer assignment, I accept the responsibility to become familiar with and abide by all of the Providence’s and Saint John’s policies, as they may change from time to time. I understand that Volunteer Services reserves the right to terminate my volunteer status as a result of failure to comply with policies, rules and regulations, chronic absences or absences without prior notification, unsatisfactory attitude, work or appearance, and any other circumstances which, in the judgment of the Volunteer Services director or manager would make my continued service as a volunteer contrary to the best interests of the hospital.
In accordance with the Fair Credit Reporting Act, this notice is to advise you that if you are offered a volunteer Position, Providence or Saint John will require a criminal history background (a consumer report) about you for volunteer placement purposes. In addition, if you are offered a volunteer position that requires driving, Providence or Saint John will require a motor vehicle record check (a consumer report). If you are offered another position that requires a check of other consumer reports, reports will be obtained.